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Owner Occupied Payment Agreement (OOPA) Application 自住房产纳税协议（OOPA）申请表
自住房产纳税协议（OOPA）项目可以让拥有并居住在自己家的人，以支付得起的方式每月 缴纳逾期未缴的房产税。无需缴纳首付，且您的每月支付金额将依照您月收入百分比而定。 所有人必须完整填写此申请表的 1-4 页。您也许需要完整填写其他附加表单。您可以在 www.phila.gov/oopa 网站上“forms” 这一项下获取这些表单，或拨打电话（215）686-6442 求助。
Do you live in the property？您是否住在该房产中？ YES 是 NO 否
如果您选择否，则您不符合申请 OOPA 的资格。OOPA 项目仅适用于拥有且居住在自己家中的人。您可能仍然符合标准纳税协议（Standard Payment Agreement）的资格。详情请浏览www.phila.gov/payment-plans
Applicant Information 申请人信息
Applicant Name 申请人姓名
Social Security Number 社保号码
Property Address 房产地址
OPA Account Number 房产评估办公室（OPA）账号
Mailing Address 邮寄地址
Birth Date 出生日期
Phone 电话
Email Address 电子邮箱
How many people live in your household?家中人数？
Section 2 - Document Check List 申请所需文件清单
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Ownership and ID (provide one) 业主身份证件（提供一项）
• Photo ID issued by the U.S. Federal Government, or Commonwealth of Pennsylvania, or City of Philadelphia 由美国联邦政府或宾夕法尼亚州政府或费城市政府颁发的带有照片的身份证件。
Residency (provide two showing current address) 住址证明（提供两个标明目前住址的文件） • Utility Bills (PECO, PGW, PWD), or
水电费单（PECO 电费，PGW 燃气费，PWD 水费）或 • Photo ID issued by the U.S. Federal Government, Commonwealth of Pennsylvania or
City of Philadelphia, or 由美国联邦政府或宾夕法尼亚州政府或费城市政府颁发的带照片证件，或
• Social Security (SSA, SSDI, SSI) award letters 社会安全局（SSA，SSDI，SSI）发放的福利裁决通过证明
如果您有逆按揭(Reverse Mortgage)，请在签署此协议前联系您的贷款方。一旦您理解了协议的偿还条件，请联系您的贷款方以确保他们会接受这些条件。
注：请用英文填写表格
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YES 是 NO 否 Do you have a permanent disability?
您是否有永久残疾？
YES 是 NO 否 Is your spouse deceased?
您配偶离世了吗？
Owner Occupied Payment Agreement (OOPA) Application
自住房产纳税协议（OOPA）申请表
A. Additional Application Information 额外信息 请就下述问题回答“是”或“否”。基于您回答，您可能需要提供更多的信息。
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YES 是 NO 否 Is your name on the deed of your home?
您的名字是否在您的房契上？
YES 是 NO 否 Is your name on the property tax bill?
您的名字是否在该房房产税账单上？
如果以上任意一题您的回答是否，则您必须填写 Tangled Title Worksheet，此表在 www.phila.gov/oopa 的“forms”一项下，或拨打电话（215）686-6442 求助。
什么是错综复杂产权（Tangled Title）？错综复杂的产权即是指您拥有一处房屋的所有权权益，但您的名字却不在
房契上。比如，也许您居住在原业主已离世的房子里，或您有先租后买的租赁协议。如果您不确定是否拥有错综复杂
的产权，请咨询税务局代表或房产法律顾问。
如果以上任意一题您的回答“是”，请提供额外文件：
Disability (need one) / 残疾 （需要一项）
* SSDI/VA/Black Lung award letter, or 社会保障残疾保险（Social Security Disability Insurance）/退伍军人管理局(Veteran’s Administration）/黑肺病证明（Black Lung award letter），或 * Physicians Statement proving disability, use the Disability Verification Form found at www.phila.gov/oopa under “forms” or call (215) 686-6442. 医生提供的残疾证明，使用《残疾证明表》，您可在www.phila.gov/oopa 的“forms”这一项下找到此表或拨打电话（215）686-6442 求助。
Widowhood /寡居
* Copy of death certificate of spouse/配偶死亡证明副本
YES 是 NO 否 Do you have a reverse mortgage? 您是否有逆按揭？
此付款协议可能违反您的逆按揭合同。我们希望您在签署协议前先向免费的房产顾问咨询。在咨询前请先完成本表 3B 部分。您也需联系你的贷款方。
B.Do you want free housing counseling? 您需要免费的住房咨询服务吗？
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在签署协议前向免费的住房咨询顾问交谈，也许有助于制定出最适合您的计划。住房咨询顾问也可以帮助您申请宅地豁免以减少年税。您也可能有资格申请免费的法律援助。
Would you like to be referred to free housing counseling? 您想要接收免费的住房咨询服务吗？ YES 是 NO 否 If you answered YES 如果您回答是： What is the best number to reach you? 您的最佳联系电话号码是？
What is the best time to call you? 联系您的最适宜时间是？ MORNING 早上 AFTERNOON 下午 EVENING/晚上
注：请用英文填写表格
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Owner Occupied Payment Agreement (OOPA) Application 自住房产纳税协议（OOPA）申请表
A. Household Income - all applicants 家庭收入-所有申请人 请在下表中填写家庭月收入
INCOME SOURCE
收入来源
APPLICANT
申请人
SPOUSE
配偶
HOUSEHOLD
MEMBERS 家庭成员
TOTAL
合计
Social Security Benefits (include SSI, SSD, etc.)社会保障
福利（包括 SSI,SSD 等）
Take-Home (net) Pay 税后（净）工资
Pension 退休金
Unemployment Compensation 失业补偿金
Net Self-Employment Income 净自雇收入
Net Rental Income 净房租收入
Other 其他
Other 其他
Totals 合计
Including current year taxes in your OOPA 在您的 OOPA 中囊括本年度的税款
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Section 4-Document Checklist 第四部分-文件清单 You will need to provide proof of income. Please provide all that apply to you. 您需要提供收入证明。请提供所有适用于您情况的文件 • Pay stubs from current employer 现任雇主开具的工资存根 • W-2 or state/federal tax return W-2 或州/联邦税务申报单 • Social Security (SSA, SSDI, SSI) award letters 社会安全局（SSA，SSDI，SSI）发放的福利裁决通过信 • Pension statements 退休金结算单 • Unemployment/Workers compensation statements or award letters 失业/员工补偿金结算单或福利裁决通过信 • Other documentation as needed 其他所需文件
B. Household Income - Applicants with no income to report 家庭收入-无收入申请者申报
Check this box if you have no monthly income. 如您无月收入请勾选此框
You must complete the Zero Income Worksheet found at www.phila.gov/oopa under “forms” or call (215) 686-6442. 您必须完整填写 Zero Income Worksheet，此表可在 www.phila.gov/oopa 的“forms”一项下找到，或拨打电话（215）686-6442 求助。
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If the Department of Revenue determines you are eligible, it will automatically include current-year taxes in your agreement AND apply payments to current-year taxes first.
如果税务局确定您符合资格，您的协议中将自动包括本年度的税款，并且会将缴纳税款首先用于支付本年度税务。 I do not want to include current year taxes in my OOPA. If you opt-out, you MUST pay
your current year taxes in addition to your OOPA. If you do not pay, you will breach your agreement. 我不想在我的 OOPA 中包括本年度税款。如果您选择不参加，则除了 OOPA 之外您还必须缴纳您本年度的税款，如果您不缴，则即视为违反协议。
4 注：请用英文填写表格
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Owner Occupied Payment Agreement (OOPA) Application 自住房产纳税协议（OOPA）申请表
Ver 20180919
How should we calculate your monthly payment? 我们应如何计算您的每月支付金额？
Should we contact anyone else about this application?
有人帮助您完成这份申请吗？
Check here if you are working with someone to complete this application. If checked, please provide their name and contact information: 如果有人帮助您完成此申请，请勾选此处。如勾选，请提供他们的姓名和联系信息。
No. I am not working with anyone. 不，我是自己完成这份申请的
Signature 签名 The Department of Revenue will also use this application to enroll you in the Homestead Exemption program if you do not already have it. The Homestead Exemption can save you money on your property taxes. If needed, the City will make its best efforts to contact OOPA applicants and participants. This may include letters, phone calls, emails, or SMS (text) messages. 如果您还没有参与宅地豁免计划，税务局也会用此申请为您注册。宅地豁免可以为您节省房产税。如有需要，费城市政府也会尽力联系 OOPA 申请人及相关人员。联系方式或包括信件，电话，电邮或短信。
I have reviewed all the information on this form, and on any accompanying statements or forms. This information is true and correct to the best of my knowledge, information and belief. 本人已检查过此表格上以及附属声明或表格上的所有信息。并保证就本人一切所知，所悉，所信而言，信息皆真实且正确。
Applicant Signature 申请人签名 Date 日期
Applicant printed name 申请人姓名（印刷体）
Email Completed forms to 将完成的表格发送电子邮件至: [email protected]
或将表格邮寄至以下地址：
City of Philadelphia Department of Revenue, Taxpayer Services P.O. Box 53250 Philadelphia, PA 19105
或亲自将表格交至以下地址： Municipal Services Building Department of Revenue 1401 John F. Kennedy Blvd—Concourse Philadelphia, PA 19102
Hope Plaza N. 22nd & W. Somerset St. Philadelphia, PA 19132
Northeast Municipal Services Center 7522 Castor Ave. Philadelphia, PA 19152
Monthly payment based on a percentage of your income. This is usually the most affordable option and no additional documents are required. 基于您收入的百分比设定每月支付金额。通常这是最经济的一种选择，且不需要额外文件。 Monthly payment based on an individualized review of your income and expenses. This option requires that you disclose information on your monthly expenses in addition to your monthly income. We reserve the right to disallow expenses that are not reasonable and necessary. 基于对您收入与支出个性化设定每月支付金额。此项需要您披露自己的月收入以外，还要披露您的月支出信息。我们有权驳回不合理以及不必要的支出.
You must complete Section 4A on page 2, and the Monthly Expenses Worksheet found at www.phila.gov/oopa under “forms” or call (215) 686-6442. Please provide documentation verifying each expense.
您必须完成第二页上的 4A 部分，以及 Monthly Expenses Worksheet，此表可在 www.phila.gov/oopa 的“forms”一项下找到，或拨打（215）686-6442 求助。请提供每项支出的证明文件。
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6 注：请用英文填写表格
Ver 20180401
I, , hereby make the following statements of fact subject to the penalties of 18 Pa.C.S. § 4909 relating to unsworn falsification to authorities, that to the best of my knowledge, information, and belief: 本人， ，在此声明，本人就本人一切所知，所悉，所信做出如下声明，且其受到 18 Pa.C.S. § 4909(关于以未宣誓的伪造欺骗当局）条款约束。 1. I currently reside at , Philadelphia, Pennsylvania (“the property”). 本人目前居住在___________________________________________费城， 宾州（“住址”） 2. I have resided at this address for ______ years and _____ months. 本人已在此地址住了 年又 月。 I have not moved or maintained a primary residence at any other address during this timeframe. 在此期间本人没有搬至或以其他地址作为本人的主要住所。 3. I have an ownership interest in the property because (check any that apply): 本人享有此处房产的所有权权益因为（勾选任意适用项）：
自住房纳税协议 错综复杂产权补充表 You should complete this form if your name is not on the deed to the home you live in, but you have a legal interest in the property. 如果您的名字不在您住房的房契上，但您享有该房产的合法权益，您需要填写此表。
You must submit supporting documentation with this form. Please see the other side of this sheet for more details. 您必须将证明文件同此表一并提交。需要更多细节请浏览此表另一面。
所有权权益确认
签名
I intend to take all reasonable efforts to obtain a deed to the property within the next 3 years. 本人打算在接下来的三年里尽一切合理努力取得该房房契。 I have attached supporting documentation (see the other side of this form for more information) 本人已经附加了证明文件（更多信息请浏览此表另一面）
I declare that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge, information and belief.
本人声明，本人已检查过此表以及其他任何附属声明或表格上的所有信息，并保证就本人一切所知，所悉，所信而言，它们皆真实且正确。
Signature 签名 Date 日期
将完整填写的表格和文件与您的 OOPA 申请放在一起。 Contact (215) 686-6442 with questions about this form. 对此表有疑问请联络（215）686-6442
I inherited the property from (name of previous property owner): 本人从: （前业主名字）处继承了该房产。
Their relationship to me is: 他们和本人的关系是：
I inherited the property in this month and year (usually when the owner on the current deed died): 本人于此年此月继承了该房产： （通常是当房契上的业主去
世时）
I purchased the property from (name of previous property owner): 本人从: （前房主名字）处购得了此房产。
This purchase was through a rent-to-own agreement in this month and year: 本人通过先租后买协议于此年此月: 购得了该房产。
I have some other ownership claim which I describe further here:
本人还有其他的房屋产权请求，详述如下：
注：请用英文填写表格
Ver 20180401
自住房产纳税协议 错综复杂产权补充表-所需文件
文件核对表 如果您的名字不在您房产的房契上，但您确信自己享有该房所有权权益，您必须提交下列文件的其中之一。 您可以提交下列文件中的多项以证明您的所有权权益。比如，如果您的母亲与该房业主签署了先租后买协议后您的母亲去世了，您可以提供证明先租后买协议的文件，以及证明您与您母亲亲属关系的文件。
Proof showing that you lived in the property at least 14 years ago. 证据显示至少 14 年前您居住在该房。 If you were the owner listed on the deed but a fraudulent deed was recorded taking title out of your name: 如果您以前是房契上的业主但在记录显示有一份假房契盗取了您名下的所有权。 • A police report that you have filed for the
fraudulent deed (“property theft”), or 您已提交的假房契报案证明（“房产盗窃”），或 • Proof of court action (e.g., a “complaint”) that has been filed
in court to get rid of the fraudulent deed. 为处理假房契，已向法院提起诉讼的法院诉讼证明（例如，“诉状”）
If your relative was the owner listed on the deed (the “original owner”) but a fraudulent deed was recorded taking title out of the original owner’s name: 如果您的亲戚是房契上的业主（“原业主”）但记录显示有一份假房契盗取了原业主名下的所有权。 The deed where the original owner got title AND the death certificate of the original owner AND documentation from one of the categories listed below (numbers 4 through 10) showing your connection to the original owner, or 原业主拥有所有权的那份房契，以及原业主的死亡证明以及下列类别（从 4 到 10）其中之一能证明您与原主关系的文件，或 • A police report that you have filed for the fraudulent deed
(“property theft”) AND documentation from one of the categories listed below (numbers 4 through 10) showing your connection to the original owner, or 您已提交的假房契报案证明（“房产盗窃”）以及下列类别（从 4 到10）其中之一能证明您与原主关系的文件，或
• Proof of court action (e.g., a “complaint”) that has been filed in court to get rid of the fraudulent deed. 为摆脱假房契，已在法院提起诉讼的法院诉讼证明（例如，“诉状”）
A deed that puts title into your name that is notarized, but which has not been recorded at the Recorder of Deeds. 将所有权赋予至您名下并已被公证但还没在房契记录局(Recorder of Deeds)登记的房契。 A divorce decree, or other family court order, that gives you title to the property. 赋予您该房所有权的离婚判决，或其他家庭法院令。 Letters Testamentary or Letters of Administration that name you as the executor/administrator of the property owner’s estate – either a certified copy or a copy with the Register of Wills’ seal on it. 命您为该房业主地产执行人/管理人的遗嘱或行政书-经核证的副本或有遗嘱处盖章的附件。 The property owner’s death certificate AND a 该房业主的死亡证明和（以下文件） marriage certificate that shows that you and the property owner were married – either certified copies or copies with the Pennsylvania Department of Health’s seal on it. 能证明您与该房业主结婚的婚姻证明-经认证的副本或有宾夕法尼亚卫生局（Pennsylvania Department of Health）盖章的副本。
The property owner’s death certificate AND your birth certificate that lists the property owner as your mother or father – either certified copies or copies with the Pennsylvania Department of
Health’s seal on it. 该房主的死亡证明以及您的出生证明（其上列有您的母亲或父亲即该房产业主）- 经核证的副本或有宾夕法尼亚卫生局盖章的副本。 The property owner’s will that leaves the property to you AND the property owner’s death certificate (the death certificate must be either a certified copy or a copy with the Pennsylvania Department of Health’s seal on it). If the property owner’s will leaves the property to someone else, and that other person then left a will leaving the property to you, you should provide wills and death certificates for both people. 指明将该房留给您的该房主遗嘱，以及该房产业主的死亡证明（死亡证明必须是经核证的副本或有宾夕法尼亚卫生局盖章的副本。）如果该房业主在遗嘱中将该房留给其他人，而那个人又在其遗嘱中将该房留给了您，则您需提供此二人的遗嘱和死亡证明。 A rent-to-own agreement (AKA lease/purchase agreement or installment land contract) signed by the property owner AND documentation showing that you have made payments to the property owner in at least 3 different months. 由该房主签署的先租后买协议（又称租赁/购买协议或分期土地合同）以及证明您已在至少三个不同的月份向该房主付款的文件。 A letter from an attorney who is helping you get title to the property – The letter should be on the law firm’s letterhead; explain the facts and your legal claim to the property; state that the attorney is representing you to help you obtain title; state that the attorney will notify the City if he/she stops representing you; and include the attorney’s Pennsylvania attorney identification number. 帮您争取该房所有权的律师信-该信的信笺上需印有其法律公司的抬头；信中需解释事实以及您对该房的法律诉求；需声明此律师是代表您，帮您争取所有权； 需声明如果此律师不再代表您，则他/她会告知费城政府；且信中还需包括此律师的宾夕法尼亚州律师证号码。 A letter from a legal services agency that is helping you get title to the property – The letter should be on the agency’s letterhead; explain the facts and your legal claim to the property; state that the agency is looking for an attorney to help you obtain title; state that the agency will notify the City if it is not able to find an attorney to help you; and include the Pennsylvania attorney identification number for an attorney at the agency. 帮您争取该房所有权的法律服务处的信件-该信的信笺上需有此机构的抬头；信中需解释事实以及您对该房的法律诉求；需声明该机构正在为您寻找能帮您争取所有权的律师；需声明如果该机构无法找到律师来帮助您，则会告知费城政府；信中还需包括一位服务于该机构的律师的宾夕法尼亚州律师证号码。
注：请用英文填写表格
Ver 20180401
自住房产纳税协议（OOPA）开支补充表
This form is ONLY to be used if you want a payment agreement based on a comparison of your income and expenses. 仅当您希望根据您的收入和支出的差额达成付款协议时，才能使用此表。
You must disclose your household income and how you spend your money in a month. We reserve the right to disallow expenses that are not reasonable and necessary. Any extra money in your budget must be paid to property taxes. 您必须公开您的家庭收入，以及您在一个月之内的消费开支。
我们有权驳回不合理以及不必要的花销。您预算中的任何额外款项必须用来支付房产税。
申请人信息
Applicant Name 申请人姓名
OPA Account Number OPA 账号
家庭开支
Please use the worksheet below and enter average monthly household expenses: 请在下表中填写每月平均家庭开支
HOUSING EXPENSES
住房开支
AMOUNT
数额
LIVING EXPENSES
生活开支
AMOUNT
数额
LIVING EXPENSES
生活开支
AMOUNT
数额
First Mortgage
首次贷款
Telephone
话费
Car Loan
车辆贷款
Second Mortgage
第二次贷款
Groceries (exclude Food Stamps)
杂货（不包括食品券）
Car Insurance
车辆保险
Current Year Property Taxes
本年度房产税
Clothing
衣物
Car Maintenance (oil changes, repairs)
车辆维护（更换机油，维修）
Homeowner’s Insurance
房屋保险
Laundry
洗衣
Transportation (gas, SEPTA) 通勤费（汽
油费，SEPTA 公交费）
Electric Service
电费
Toiletries and Paper Goods
卫生用品及纸类产品
Child Support / Alimony
子女抚养/赡养
Gas Service
燃气费
Housing Allowance (People in the home x $40)
住房津贴（人数 X$40)
Tithe/Religious Donation (not more
than 10% of income)
宗教捐赠（不超过收入的 10%）
Water / Sewer Service
水/下水道费
Other Household Goods
其他家庭用品
Life Insurance
人寿保险
Oil Service
油费
Medical and Dental Expenses
医疗及牙科开支
Other
其他
Home Maintenance
房屋维护费
Medical and Dental Insurance
医疗和牙科保险
Other
其他
Child Support/ Alimony
子女抚养/赡养费
Prescriptions
处方药费
Other
其他
HOUSING SUBTOTAL
住房开支总额 $
LIVING EXPENSES SUBTOTAL
生活开支总额 $
LIVING EXPENSES SUBTOTAL
生活开支总额 $
TOTAL OF ALL EXPENSES 合计开支
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注：请用英文填写表格
Ver 20180401
自住房产纳税协议（OOPA） 开支补充表 自住房产纳税协议（OOPA）开支补充表
计算 Subtract expenses from your income to calculate tax payment amount 从您的收入中减去开支以计算缴税数额
A. Total Household Income (from page 2 of OOPA application)
家庭收入总额（OOPA 申请表的第二页）
B. Total Household Expenses (from previous page)
家庭开支总额（上一页） C. Amount available for monthly Real Estate tax payment
可用于每月缴纳房产税的数额
签名
I declare that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge, information, and belief. 本人声明本人已经检查过此表及任意附属声明或表格上的所有信息，并且保证就本人一切所知，所悉，及所信，这些信息均真实且正确。
Applicant’s Signature 申请人签名 Date 日期
Applicant’s Printed Name 申请人印刷体姓名
OPA Account Number 房产办公室（OPA）账号
将完整填写的表格及文件和您的 OOPA 申请表放在一起 Contact (215) 686-6442 with questions about this form.
对此表有疑问请联络（215）686-6442
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$
$
注：请用英文填写表格
Ver 20180401
自住房产纳税协议（OOPA)零收入补充表
This form is ONLY to be used if you have no monthly income.
此表仅适用于无月收入人群。
申请人信息
Applicant Name 申请人姓名
OPA Account Number OPA 账号
零收入确认 I affirm that I have no income at this time. When my income commences, I will immediately notify the
City of Philadelphia Department of Revenue.
本人证实本人目前没有收入。当本人开始有收入时，本人将立即告知费城税务局。
The information I have provided is true and complete to the best of my knowledge.
就本人一切所知，本人所提供的信息真实且完整。
Applicant’s Signature 申请人签名 Date 日期
Applicant’s printed name 申请人签名(印刷体)
注意 Section 19-1305 of the Philadelphia Municipal Code states: No person shall intentionally make any
false statement when applying to enter into an installment payment agreement. If it is determined that
a taxpayer entered into an installment payment agreement on the basis of an intentionally false
statement, the agreement shall be null and void. 费城市政法规第 19-1305 条规定：在申请签订分期付款协议时任何人不得故意做出虚假声明。
若纳税人签订分期付款协议时故意做出虚假声明，则该协议作废。
将完整填写的表格与您的 OOPA 申请表放在一起 Contact (215) 686-6442 with questions about this form.
对此表有疑问请联系（215）686-6442。
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注：请用英文填写表格
Ver 20180401
I certify the claimant named above is my patient and is permanently and totally disabled under the standards that the federal Social Security Act or the federal Railroad Retirement Act requires for determining permanent and total disability. Upon request from the Philadelphia Department of Revenue, I will provide the medical reports or records indicating diagnosis and prognosis of the claimant’s condition, including signs, symptoms and laboratory findings, if applicable or appropriate. 本人证明上述声明人是本人的患者，且根据《联邦社会保障法》或《联邦铁路退休法》评定永久及完全残疾的标准，此索赔人是永久及完全残疾的。根据费城税务局的要求，本人会提供表明此索赔人病情的诊断或预后医疗报告/医疗记录，包括体征，症状，临床发现（如适用或适当）。
Physician’s Signature 医生签名 Date 日期
A claimant not covered under the federal Social Security Act or the federal Railroad Retirement Act who is unable to submit proof of permanent and total disability may submit this Physician’s Statement. The physician must determine the claimant’s status using the same standards used for determining permanent and total disability under the federal Social Security Act or the federal Railroad Retirement Act. CAUTION: If the claimant applied for Social Security disability benefits and the Social Security Administration did not rule in the claimant’s favor, the claimant is not eligible for an OOPA based on a disability, but may meet income eligibility limits. 《联邦社会保障法》（the federal Social Security Act）或《联邦铁路退休法》（the federal Railroad Retirement Act）未覆盖到的声明人，如果不能提交永久及完 全残疾证明，可以提交这份医生证明。医生必须用和《联邦社会保障法》或《联邦铁路退休法》用以评定永久及完全残疾一样的标准来评估声明人的状况。
注意：如果声明人申请了社会保障残疾福利，而社会保障局没有批准其申请，则就此种残疾情况而言，此索赔人不符合申请 OOPA 的资格，但可能符合收入
资格限制。 Do not submit medical records unless requested by the Philadelphia Department of Revenue. 除非费城税务局要求，否则不要提交医疗报告。 Confidentiality Statement. All information on this Physician’s Statement and claim form is confidential. The department shall only use this information for the purposes of determining the claimant’s eligibility for an Owner Occupied Payment Agreement. 保密声明。此医生证明和索赔申请表上的所有信息皆为保密。费城税务局仅将这些信息用于评估声明人的自住房产纳税协议申请资格。
自住房产纳税协议（Owner Occupied Payment Agreement, OOPA）
残疾证明表- 永久及完全残疾人医生证明
Applicant Information 申请人信息
Applicant Name 申请人姓名
OPA Account Number OPA 账号
Physician’s Certification 医生证明
Description of Disability 残疾描述
Describe the Claimant’s Permanent and Total Disability. Briefly describe the reason(s) the above-named claimant is totally and
permanently disabled.请描述该声明人的永久及完全残疾状况。简短地描述上述索赔人的完全及永久残疾的原因。
Physician Identification Information 医生身份信息
请将完整填写的表格和您的 OOPA 申请表放在一起。 Contact (215) 686-6442 with questions about this form.
如对此表有疑问，请致电（215）686-6442。
Name 名字 National Provider Identifier 国家医疗服务提供者识别码
Business name, if applicable 公司名称，如适用
Address 地址
City 城市 State 州 Zip code 邮政编码
Office email address 办公室邮箱地址 Office telephone 办公室电话
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注：请用英文填写表格
Owner Occupied Payment Agreement (OOPA)
Disability Verification Form –
Physician’s Statement of Permanent and Total Disability
